advanced heart failure and cardiac transplantation fellowship

Advanced Heart Failure and Transplant Cardiology FellowshipUniversity of Utah School of MedicineDivision of Cardiovascular Medicine

and the UTAH Cardiac Transplant Program

Introduction

• This presentation will review multiple aspects of our program including:

• History of the program.• Hospitals and faculty affiliated with the program.• Transplant and mechanical support volumes. • Subspecialty clinics affiliated with the program.• Training curriculum for the fellowship.• Research at the University of Utah.• Living in Salt Lake City.

U.T.A.H. (Utah Transplantation Affiliated Hospitals) Cardiac Transplant Program

• A unique consortium of 3 adult and 1 children’s hospitals.• Common recipient list and shared donor call.• Weekly joint meetings to evaluate new candidates and update on

significant events occurring post-transplant.• Standardized treatment protocols for all aspects of care.• Shared database leading to collaborative research.

• As of June 1, 2020 we have performed 1,629 heart only, heart-kidney and heart-liver transplants.

• Since the inception of the program, transplant survival has always met or exceeded the expected survival as defined by UNOS.

• 1960's, 70's, 80's: Pioneering Mechanical Circulatory Support (MCS) - Willem Kolff (“Father of Artificial Organs") & Multidisciplinary Clinical - Research Team Developed: a) IABP Counterpulsation, b) Total Artificial Heart (TAH)

• 1982: 1st worldwide durable TAH (Jarvik 7) implanted in Barney Clark: "Moonshot effect" for MCS field

• 1985: 1st Heart Transplant (Tx) at the UTAH program• 1985-1995: Human tissue research from explanted hearts of Tx recipients + Clinical Studies

fueled the UTAH-led “Beta Blocker revolution” in HF therapy • 1993: 1st Durable LVAD implant at the UTAH program • 1995: UTAH-led Myocarditis Treatment Multicenter Trial• 2003: CMS National Approval for LVAD Destination Therapy (DT) - UTAH program: Top Enroller

+ Best Outcomes among REMATCH Trial sites • 2009: 1000th Heart Transplant: “1000 Lives Saved” recognition at the Utah State Capitol• 2014: 1st durable LVAD Explanted for Myocardial Recovery (RESTAGE Multicenter Trial)• 2015: “SHOCK TEAM” for Cardiogenic Shock management

Institutional Memory Matters!HF, Transplant, MCS Programmatic Milestones

1982, Total Artificial Heart: a Worldwide

Utah 1st

History Keeps Repeating ItselfMore to come... On-going innovative work in several CV fields!

• Long QT Legend: Revolutionized Arrhythmia and Pharma World

• Defined Role of EP Studies and EKG Holter in Arrhythmias• Beta-Blocker Therapy in HF• Defined Myocarditis Diagnosis & Therapy• Gene Discoveries: Cardiomyopathies, HHT, Supravalvular

Stenosis and many others

• Pioneering Mechanical Circulatory Support: IABP + Total Artificial Heart + Continued Driver of Innovation

• U.T.A.H. Cardiac Transplant Program: Driving Innovation + one of handful programs worldwide >1600 Transplants

• Antibody Mediated Rejection (AMR) Legend in Heart Transplantation

Utah's Innovations & Contributions to the Cardiovascular FieldInstitutional Memory Matters!

Advanced Heart Failure and Transplant Cardiology Fellowship at Utah• Training program started in 1987 and has included over 60 fellows.

• ACGME accreditation in July 1, 2012.

• 19 fellows have completed ACGME training in our program.

• Since formal accreditation all of our graduates have entered full time heart failure positions in either an academic or community practice.

• All 10 fellows who have taken board examination to date have passed.

• Heart Failure Positions Taken By Fellows Graduating From Utah Over the Last 10 years

Type ofPractice

GeographicLocation

Hospitals

UTAH Cardiac Transplant Program

University of Utah Hospital

• 425 bed hospital serving the Intermountain West.

• Cardiovascular Intensive Care Unit.• Independent Cardiology and

Cardiothoracic Surgery services.• Coverage by general cardiology fellow

and medicine resident. • Inpatient Heart Failure Service.

• Coverage by medicine resident and advanced practice clinician.

• Outpatient Heart Failure Clinic.• Operates five days a week• 90 to 100 patient visits per week.

Intermountain Medical Center

• 504 bed hospital serving as the flagship for Intermountain Healthcare.

• Cardiovascular Intensive Care Unit.• Coverage by Intensivists.

• Inpatient Heart Failure Service.• Coverage by Advanced Practice

Clinicians.• Outpatient Clinic.

• Operates five days a week.• 170-190 patient visits per week.

George E. Wahlen Department of Veterans Affairs Medical Center• 121 bed hospital serving

veterans in the Intermountain West.

• One of only five VA hospitals with a heart transplant/LVAD program.

• Inpatient Heart Failure Service.• Coverage by medicine residents.

• Outpatient Heart Failure Clinic.• Operates two days a week• 25-40 patient visits per week.

The UTAH Cardiac Transplant Program’s unique location results in a referral base that is much larger than the Salt Lake City metropolitan area

• It is the only program in the intermountain region.

• Routinely receives referrals from Utah, Idaho, Montana, Nevada, Wyoming, New Mexico and Western Colorado.

• Patients have been referred from 27 states, including Alaska and Hawaii.

Salt Lake City

LVAD Centers Across the United States

Location, Location, Location

Faculty

UTAH Cardiac Transplant Program

Program Directors

Edward Gilbert, MDProfessor of MedicineProgram Director

Rami Alharethi, MDAdjunct Assistant ProfessorAssociate Program DirectorMedical Director, Heart Transplantationand Mechanical Circulatory Support at Intermountain Medical Center

Line Kemeyou, MDAssistant ProfessorAssociate Program DirectorSarcoidosis Program Director

University of Utah/VA Faculty

James Fang, MDProfessor of MedicineChief, Division of Cardiovascular Medicine

Josef Stehlik, MD, MPHProfessor of MedicineMedical Director of Heart Transplant Program

Stavros G. Drakos, MD, PhDProfessor of MedicineMedical Director of Cardiac Mechanical Support Program

University of Utah/VA Faculty

Jose Nativi-Nicolau, MDAssociate ProfessorCardiovascular Director of the Amyloidosis Program

Omar Wever-Pinzon, MDAssistant ProfessorDirector of Hypertrophic Cardiomyopathy Clinic

Kevin S. Shah, MDAssistant ProfessorCardio-Renal Program Director

Intermountain Medical Center Faculty

Abdallah G Kfoury, MDAdjunct Professor of MedicineDirector, Heart Failure Prevention and Treatment Program

Virginia B Hebel, MDCo-Director, Hypertrophic Cardiomyopathy Clinic, IMC

Michael D. McCulloch, MDDirector, Heart Failure ProgramDirector, Cardio-Oncology, IHC

Ross A. Butschek, MDAdvanced Heart Failure Cardiologist

Program Volumes

UTAH Cardiac Transplant Program

Heart Transplant Volumes at theUtah Cardiac Transplant Program

2017 2018 2019 2020*

Adult Recipients

39 45 39 23

Pediatric Recipients

6 11 12 3

TotalRecipients

45 56 51 26

* Cases up to June 5, 2020

Adult Mechanical Assist Device Volumes at UTAH Cardiac Transplant Program

2017 2018 2019 2020 YTD*

Durable Devices

52 54** 38** 22

Temporary Devices

166 201 188 112

* Cases up to June 5, 2020, ** Includes 1 total artificial heart

Programs Integrated with Advanced Heart Failure-

Transplant Team

UTAH Cardiac Transplant Program

CARDIOGENIC SHOCK?No Specific Criteria On Purpose: Instructions to Fellows For

Low Threshold in Activating Shock Team

PAGE SHOCK TEAM *

STEMI?

CARDIOGENIC SHOCK WITH STEMI(if possible two interventional attendings in the lab)1. Establish central arterial access for LVEDP measurement2. Consider MCS (See Criteria**) and simultaneously Angiogram-PCI (preferably while the patient is already mechanically supported)3. RHC (CCO Swan) ASAP

CARDIOGENIC SHOCK WITHOUT STEMI1. RHC (CCO Swan)2. Consider MCS (See Criteria**)3. Possible LHC depending on the clinical scenario

Yes No

*Shock Team:a. HF attending b. CT Surgery attendingc. Interventional attendingd. CVICU attending

** MCS (e.g. Impella, ECMO, etc) to be considered when:A. Low SBP: SBP < 90 mm Hg or MAP < 50 for > 30

minutes OR needed inotropes/ pressors to maintain SBP >90 or MAP > 50,

B. Plus ONE of the following: - PCWP or LVEDP > 15 mmHg and CI < 2.2, or- Clinical or radiological signs of pulmonary edema, or- Impaired end-organ perfusion

Cutting Edge of Cardiogenic Shock Care: SHOCK TEAM

Circulation 2019;140:98–100

A Utah First

SHOCK TEAM

Ko BS, Drakos SG. ACC 2016 AbstractCirculation 2019;140:98–100

Multi-Specialty Clinics Affiliated with the UTAH Cardiac Transplant Program

• Amyloidosis Clinic at the University of Utah and Huntsman Cancer Institute.• https://healthcare.utah.edu/amyloidosis/

• Hypertrophic Cardiomyopathy Program at the University of Utah.• https://healthcare.utah.edu/cardiovascular/programs/hypertrophic-cardiomyopathy-

program/#:~:text=Comprehensive%2C%20Expert%20Care%20for%20Treating%20HCM,for%20evaluating%20and%20managing%20HCM.

• University of Utah Pulmonary Hypertension Center. • https://healthcare.utah.edu/cardiovascular/conditions/pulmonary-hypertension.php

• Adult Congenital Heart Disease Program. • https://healthcare.utah.edu/cardiovascular/conditions/adult-congenital-heart-

disease.php

• Sarcoidosis Clinic.

• Cardio-Renal Program.

Training in Utah:What Do Fellows Do?

UTAH Cardiac Transplant Program

Goals for our Fellowship Trainees

• Acquire the knowledge and experience necessary to become an expert in the diagnosis and management of all aspects of heart failure.

• Sit for and pass the board examination for Advanced Heart Failure and Transplant Cardiology.

• Practice in either an academic or community setting with a full-time career as a heart failure specialist.

Training Goals for Heart Failure Fellows Gain Core Competency in:

Pathophysiology, prevention, diagnosis, and treatment of heart

failure.

Evaluation for advanced heart failure treatment includingheart transplantation and mechanical

circulatory support.

Understand and implement disease management strategies,

including pharmacologic, electrical device and mechanical

circulatory support as well as cardiac transplant options forthis

patient population

Indications and interpretation of right heart catheterization, heart

biopsy and various imaging modalities including

echocardiography, CT scan, MRI, and PET.

Arrhythmia mechanisms and management (pharmacologic,

interventional and device-based)

Donor management skills and donor procurement procedure and processes, as well as the intraoperative procedures for

heart transplantation and mechanical circulatory devices

Care of patients pre- and post-heart transplantation

Care of pts pre- and post-mechanical circulatory support.

Immunology of cellular and antibody-mediated rejection, as well as screening and monitoring

protocols, pharmacologic interventions

Evaluation of patients with implantable cardioverter defibrillators, implantable

hemodynamic monitors,and cardiac resynchronization

therapy.

Advanced Heart Failure Training at UTAH Cardiac Transplant Program: Role of the Fellow• Inpatient care on cardiology ward and CVICU. Time divided between the member

hospitals of the program: • Intermountain Medical Center• University of Utah Hospital• Veterans Affair Medical Center

• Outpatient continuity clinic.• Cardiac catheterization laboratory.• Elective rotations in center of excellence sub-specialty clinics:

• Pulmonary hypertension• Amyloid• Hypertrophic

• Educational activities.• Research activities.

Additional Activities

• Review of endomyocardial biopsies with cardiac pathologists.• Presentation of patients to the weekly multi-disciplinary advanced therapies

conference.• Interested fellows have the opportunity for more advanced procedures:

• Intra-aortic balloon pump and Impella placement with the interventional attending.• CardioMEMs pressure sensor placement with Dr. Gilbert.

• Elective Options:• Pulmonary hypertension• Amyloid• Hypertrophic• Sarcoid• Advanced cardiac imaging in heart failure• Cardiac Intensive Care with the Cardiac Surgery Intensivist Team for more direct hands on

training in temporary mechanical support and post-operative management of LVAD and transplant recipients

Annual Symposia at the University of Utah• Utah Cardiac Recovery Symposium (U-CARS)

• Annual meeting on ground-breaking research in the field of cardiac recovery spanning clinical, translational and basic sciences.

• Endorsed by the Heart Failure Society of America.• Internationally recognized keynote speakers have included Eugene Braunwald,

Valentin Fuster, Milton Packer and Douglas Mann.• Utah Amyloidosis Symposium

• One of a kind sub-specialty meeting is now being used as a template for similar events around the country, held bi-annually.

• Internationally recognized key-note speakers have included Giovanni Palladini, Mathew Maurer, Vaishali Sanchorawala, & Daniel Lenihan.

• Hypertrophic Cardiomyopathy Virtual Conference• HCM Strong Bighearted Warriors Virtual Conference Tour will be held November

2020 in partnership with Hypertrophic Cardiomyopathy Association

>500 international attendees

Annual International Conference Held every January

Topics Span Bedside to Bench and Back

Utah Amyloidosis SymposiumBi-Annual Conference

Hypertrophic Cardiomyopathy Virtual ConferenceHCM Strong Bighearted Warriors Tour - December 2020

Research Opportunities

UTAH Cardiac Transplant Program

Research During Heart Failure Fellowship

• All fellows are expected to develop their scholarship in the form of research and writing.

• Fellows will identify a research mentor during the first three months of their training.

• With the assistance of his or her mentor, fellows will identify a research project that can be reasonably completed during the fellowship.

• There are many opportunities for involvement in on-going clinical and translational research programs as well as co-authorship of review articles, book chapters, and other scientific publications.

• Previous fellows have presented their research at national meetings and published manuscripts in peer reviewed journals.

IMC

U of U

U of U/CVRTI

Heart Failure & Recovery

Regeneration

U of U/HHMIU Iowa

Metabolism

UTSW Karolinska

InflammationImmunity

U of UCVRTI

Wash U

Microstructural Remodeling

U of UCVRTI

U of Newcastle

MGHHarvard

Utah Cardiac Recovery Program (UCAR)

Clinical and Research

Responders Non-Responders

Animal Models

Genomics U of U / CVRTI

Allegheny

Vascular Physiology

U of U

Patient Reported Outcomes

U of U

Inova

U of U OnassisStructural/Functional

Characterization

Temple

Living in Utah• Population

• Salt Lake City: 200,544.• Salt Lake County: 1,135,649.• Wasatch Front: 2,192,225.• State: 3,101,833.

• Climate• Arid mountain desert environment.• Four seasons• Elevation 4,330 feet.

• Mountain Time Zone• Transportation

• Salt Lake City International Airport.• Ten minutes from downtown.• Delta hub.

https://uofuhealth.utah.edu/living_in_utah/

https://uofuhealth.utah.edu/why-utah.php

Salt Lake City: Life in the Mountains